Critical Condition

by Peter Clement

  Then he thought of his training when he'd first joined the movement, the month he'd spent five years ago with combat instructors in the Blue Ridge Mountains. He could snap Steele's neck, the way they taught him. Doing the feat for real would be different from performing it on a mannequin, sure. Yet as long as he got the guy from behind, it shouldn't be too difficult. And he could come back to dispatch Sullivan afterward. Because chances were, if he hid his body in some back corridor, they wouldn't find him until the morning staff came on duty at seven. That gave "Harold Glass" plenty of time to revisit ICU. Six-thirty would be best. He'd offer to clean up before the end of the night shift. The nurses would be too busy getting their charts in order for the changeover to notice him getting close to her again.

  Breathing quickly, he reached the elevator that would take him downstairs and pushed the button. A distant motor whined into action, but the wait for the car seemed to take forever. He shifted nervously from one foot to the other. He had to slow down, he told himself. He couldn't rush this. But the prospect of action had him on edge.

  When the door opened, he hesitated before getting in, his enthusiasm to go after Steele all at once wavering. Was his deviation from the original plan really the Lord's wish? How did he know Satan wasn't tempting him to stray by playing with his impatience to get the job done.

  The elevator door closed in front of him, and he looked over to the mop and bucket against the wall. The corridor was very long. He estimated he could spend another hour or two pretending to mop it end to end and no one would find it out of the ordinary. That was it. He'd trust in God to show him the way, he decided as he walked over and pulled the pail of water, its wheels squeaking, to the middle of the floor. He grabbed the wooden handle and hoisted the wad of dripping gray strings, then slapped it onto the linoleum. If He hadn't provided the opportunity to kill Sullivan by the time he'd finished, he would know He meant for him to move on to Steele. After all, he had the whole night.

  The metal wheels gave another little squeal as he nudged his way back toward ICU.

  Hamlin had operated on four types of intracranial hemorrhages in the last two years. There weren't a lot.

  Capsular angiomas like Kathleen's caused only 2 percent of all hemorrhagic strokes. As for the other kinds requiring surgical intervention, even the most common— subarachnoid leaks, or bleeding onto the surface of the brain fromcongenital aneurysms— showed up in ER only about a dozen times a year. Hemorrhages into the cerebellum, the large spheres hanging over the brain stem at the back, might arrive eight or nine times. Arterial-venous malformations— arteries pumping directly into weaker-walled veins until they burst— were slightly more common, especially in hypertensives, but only in a fraction of the cases could they be reached with a scalpel. And Hamlin wasn't the surgeon of choice in all of them. He had a department full of hungry competitors with whom he had to share any goodies amenable to the knife.

  In every category his patients did twice as well as those of any other neurosurgeon in the country. If he and Lockman were killing people, it didn't show here. "So what the hell were they up to?" Richard muttered. The sound of his own voice was a welcome respite to the steady rushing noise pouring out of the air ducts.

  Armed with a list of seven files for the year so far and thirteen for the period January 1 to December 31 of last year, he went into the maze of open-sided, ceiling-high shelves to track them down. Overhead the pipes let out a moan, then gurgled and thumped as if they were the intestines of some angry beast.

  He found it tedious work. First he had to locate each chart according to its seven-digit listing. That entailed wandering about deep within the stacks while keeping ten-digit numbers straight in his head. Some of the dossiers were reasonably slim, but others were three-volume affairs, each the size of the New York phone book.Might as well round up everything at once before looking through them, he decided, taking the first half dozen to the table where he'd been working and going back for the rest.

  Once he had them all, he began by arranging them in four piles according to diagnosis— nine patients with subarachnoid leaks, one of which had deteriorated into an outright bleed; six with cerebellar hemorrhages; three with an AV malformation; two with a capsular angioma in the brain stem. He started with the turf where he would be most at home, the patient's arrival in ER.

  In each instance they'd been seen promptly by his staff, stabilized, and transferred to Hamlin's care. But one case from over a year ago, the subarachnoid leak that had deteriorated into an outright hemorrhage, leapt out at him. Richard himself had done the resuscitation. Immediately he remembered the patient, a young man of forty-two who had come in complaining of the worst headache in his life. His wife, a slight blond woman so pale with fright that her face seemed brittle as porcelain, ran out of her husband's cubicle to get help when he suddenly slumped down on the stretcher, unresponsive.

  Richard had rushed to intubate him. As he worked, the man's bulging right eye seemed to seek him out and stare at him, its pupil dilated big as a blackened dime, a sign that the pressure of the hemorrhage was squeezing the brain out the bottom of his skull like so much toothpaste. The mouth twisted into a one-sided sneer and emitted grunting noises along with frothy spittle as he seized. For an instant Richard allowed himself to think his patient was trying to tell him something, trying to protest against having his memories, his mind, his ability to think, his very self reduced to a gray-and-white puree being emptied out like the pulp of a plant.

  He'd obviously let that one get under his skin, he thought, surprised by how clearly it all came back to him. Let too many horrors in where they could work on you, and it was burnout time, the end of most ER careers. He'd counseled enough husks of formerly good physicians to know, and had been through his own near brush with the flame.

  It wasn't just the victims who ate into your dreams and stared back at you if you let them. He could still see the young wife's eyes. Already dilated as black as her husband's in terror of losing him, they had seemed to recede into their sockets as she tried to prepare herself for the worst. Yet against all odds, he and Hamlin managed to save the man's life. In ER they had shrink-wrapped his brain down to three-quarters its size by running a half liter of concentrated mannitol through it. Hyperosmotic, it sucked the brain tissue dry, collapsing it around the ruptured vessels, slowing the bleed, and relieving the pressure that was emptying his skull of white matter. That bought enough time to get him on the OR table within a few heartbeats of being alive. Hamlin did the rest. Six hours later the woman returned with the good news, pitch embers of hope glittering where earlier there'd been hollow despair. Maybe it was the sight of her so transformed that helped him put all thought of her husband's grotesque ordeal out of mind and escape with one less haunting, for he hadn't given a thought to either of them from that time until now.

  Richard turned to the section detailing the man's course in hospital. As with most medical records the world over, the initial notes belonged to the doctors and residents. Their terse, dated entries, the handwriting varying from day to day according to the rotation of house staff who took care of him told the tale of his physiological recovery, defining the extent he was alive with a string of numbers that documented his vitals, his 02 levels, and his coma scale. Next came all the lab results, the cardiograms, and finally the X-ray reports— MRIs, CT scans, angiograms— all peering into the state of his brain. But to really see the progress of the person as opposed to the body he read the nursing notes. They were more subjective, and therefore more pertinent regarding a return to life.

  ,,, recovering movement in arms and legs ...

  ... asking for his wife ...

  ... swallowing water through a straw without choking...

  Richard marveled at what he read, never having imagined that the extent of brain damage he'd witnessed could have been reversed enough to enable the man to perform even such basic tasks. The progress notes for the second week he found more remarkable still.

  ,,, patient a
ble to feed himself...

  ... sits in chair...

  ... speech much less garbled...

  The final note deemed him stable enough for transfer to rehab, in this case at the Adele Blaine Rehabilitation Institute. Nothing unusual about that— except there were no follow-up visits to the hospital. The patient simply dropped off the radar as far as NYCH was concerned.

  Strange, thought Richard. Most people saw the treating surgeon at least once or twice after discharge. In this case, who knew how the man did afterward? Maybe this was how Hamlin ended up with such good statistics. Even if the guy died, it wouldn't show up on his NYCH record.

  He made a note of the man's name, intending to contact Blaine's rehabilitation institute in the morning and request that they give him whatever they had on file about the guy's outcome. If he said it was part of an ER audit, they might fall for it and tell him, he figured.He got up to walk around a few minutes, the coolness he'd found so pleasant on arrival having seeped into his bones. As he warmed up, he noticed that directly overhead where he'd been sitting was an air duct. "No wonder," he muttered, and pulled the desk over against a partition that separated the work area from the rest of the room. Not only did it seem warmer there, he felt more comfortable having his back to something solid. It always unnerved him a little to sit alone in such a vast open space. Tonight he felt especially jumpy, due to the aftershock of discovering Lockman's body.

  Getting back to work, he found that the admission notes in the remaining files showed a pattern similar to what he'd seen in the first. A timely, successful surgical intervention, a remarkable post-op progress, a transfer to Adele Blaine's rehabilitation institute with no follow up.

  Except on two occasions.

  One involved a man whose surgery had been a year and a half ago for a subarachnoid hemorrhage: the other was a woman who, like Kathleen, had a bleeding capsular angioma removed in April of that same year. Both of them had returned to ER, the man two months ago, the woman a few weeks later, except they were DOA.

  Intracranial hemorrhage read the death certificates signed by Hamlin. In neither case had there been an autopsy.

  His own staff hadn't seen any cause to challenge this. According to the nursing notes, the families had expressed their extreme satisfaction with Hamlin for the remarkable recovery their loved one had made from the first stroke, and didn't feel any need to confirm his diagnosis of the terminal event.

  Richard found it odd that none of his ER doctors had questioned why a person who'd had a congenital vascular malformation removed over a year earlier should have a second bleed. After all, these things didn't grow back. To suggest that both had a second vascular anomaly Hamlin had missed on the first workup invoked impossible odds.

  Were they hypertensive? he wondered, willing to grant that they could have suffered a second hemorrhage from otherwise normal arterial sites if they were already weakened by chronically high blood pressure. But he couldn't see any record of elevated BP readings on their previous admission, nor did their ER record indicate a prior history of it.

  He added these two patients and their particulars to his list, intending to see what their charts at Blaine's institute said about subsequent blood pressure readings as they became more active. He also found the names of their family doctors on the initial admission sheet. After all, it wasn't impossible the readings remained low here, what with all the morphine and bed rest, then returned to previous highs after discharge.

  Something flushed through the pipes overhead, making them groan in protest.

  Still feeling stiff, he arched his back, crossed his hands behind his head, and continued to think. Certainly these two hadn't died as an immediate result of their previous surgery by Hamlin. It had been over a year between the operations and their deaths. So how had they done in the meantime?

  He flipped through the ER documents to the names and phone numbers of their next of kin. He'd also phone them tomorrow and ask.

  Again he leaned back in his chair. Could Blaine be in on some kind of cover-up with Hamlin? If so, why? His previous numbers for morbidity-mortality were completely respectable.

  Once more recalling the heated exchange he'd witnessed between her and the neurosurgeon along with the others in the cafeteria, he played with the idea of specifically confronting her before setting McKnight on the bunch of them. Or might his asking about the two killings make the woman shut up completely and hide behind a lawyer just as quickly as the police speaking to her would?Rather than single her out just now and jump to any conclusions that she was part of something he couldn't yet identify, he'd better check the files of those patients at her institute and see what really happened to them. In fact, without evidence of any wrongdoing, she, Edwards, and Downs could all claim they'd been fighting about anything. Certainly the last thing he should do was antagonize her at this point since even if she wasn't involved, his getting at those rehab records might still be crucial to figuring out what Hamlin and Lockman were up to. He should approach her as a colleague, requesting her help to uncover Hamlin's secret without suggesting he suspected her of involvement with the surgeon. He completed a list of all the people whose records he'd ask her about, recording their names, birth dates, and phone numbers.

  Something else he should look at, he thought, flipping back to the section for X-ray reports in each dossier.

  Sure enough, in every case the patients had an angiogram, the radiologist on record being Lockman.

  But Richard couldn't spot anything else out of the ordinary. So what had the neurosurgeon done to them that he and Lockman feared he would find out? The OR reports, the record of what Hamlin had actually performed during surgery in all twenty cases certainly didn't suggest anything, at least nothing causing obvious harm. The majority of these lengthy accounts were dictated solely— and in mind-numbing detail— by his residents, then checked and signed by them, which seemed to rule out the possibility of Hamlin having altered them.

  Assuming his statistics were true, did it mean that whatever he'd done to improve them had occurred solely during the angiogram?

  Not necessarily, if Hamlin had managed to pull a fast one right under the residents' noses.

  What sort of fast one?

  Something that, after making everyone do so extraordinarily well, also killed them. Killed them with another bleed, the way these last two died.

  And if it killed them, would it kill Kathleen?

  Rage tumbled through him like a flash flood. What if he never found out what they'd done to the other patients and Kathleen in time to help her?

  Crazy ideas screamed through his head. He suddenly didn't feel so sure about pussyfooting around Blaine. An hour alone with her might be all he needed to make her tell what she knew.And if she along with Edwards and Downs were the "others" that Lockman had referred to, were they also the ones who killed him and Hamlin? Visions of the radiologist's body reinforced for Richard the idea that the killer's handiwork itself indicated he or she was someone with a medical background. Certainly Downs could have managed it. Edwards, too, for that matter because after all, a surgeon was a surgeon, even if he normally operated only on females between the navel and the knees.

  But despite his desperation to pounce on a definite answer, his instincts as a physician pushed him to consider all logical solutions, the same way he would entertain all reasonable diagnoses in a sick patient. Again he vacillated between his suspicions about the three and the possibility they'd nothing to do with the whole affair, that someone about whom he'd no idea held the secret of what had been done to Kathleen. Without proof to the contrary, he was back to admitting Lockman's killer could have been anyone with training, just as he'd initially told Mc Knight.

  I'll hunt them down, so help me, and make them tell me what Hamlin did to Kathleen, even if I have to grill everyone in this hospital. He gave a shudder, a flurry of faces and names flashing through his head, until he suddenly thought, Oh my God, look what I'm doing. He felt sick to his stomach.

&nbs
p; Leave the trapping of the murderer to the cops, he tried telling himself. Yet his sense of being personally responsible for doing so— something from the realm of a "Hail Mary"— persisted. In the pit he'd pulled his share of desperate moves resorted to only when all else had failed and there was nothing to lose. He also knew when it wasn't going to work. He'd feel as if an icy hand reached up to rake through his own innards before it pulled whomever he was working on into his, or her, grave.

  He'd have to be careful who he fingered to McKnight, he finally decided, still unclear about what he should do on his own. Yet he was determined to keep his options open, ready to try anything that would help Kathleen, even if it meant working without the cops.

  Looking at his watch, he saw that it was four A.M. Since ICU hadn't called him, he figured Kathleen must be sleeping normally, the drug having worn off by now. Better she rest, he decided, seeing no advantage to waking her. She could tell him in the morning what upset her so. Besides, there was more he could do here, and he proceeded to follow up on a hunch. If he concentrated on the years just prior to the spectacular fall in Hamlin's morbidity-mortality rates, he might twig to what was done differently, however insignificant it might seem, around the time of the change. That might be the key to whatever fast one the neurosurgeon had pulled.

  Punching the appropriate keys, he asked for the list of Hamlin's patients corresponding to 1998 and 1999. When he had the numbers of the files, he arranged them in ascending order to make his retrieval of them more systematic. As a result, the more actual dossiers he picked up, he found himself having to go further and further into the warren of charts and aisles. The steady noise of the air-conditioning and the industrial carpet underfoot dulled any sounds he made as he walked until he seemed to be moving about in virtual silence. "Like one of the ghosts I've heard down here," he muttered, once again trying to find comfort from the sound of his own voice. But the muffling rush from the overhead ducts increasingly bothered him, as did the realization that if anyone else ever did come in here, he wouldn't hear them. However useful a conversation with the killer might prove to be, Richard's having conceded the person could be anybody from the hospital had him feeling edgy and looking over his shoulder.